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Benign Colorectal Disease 1 Flashcards

1
Q

etiology of small bowel ischemia (approach to ddx)

A

arterial occlusion (is afib)

venous occlusion

hypoperfusion/vasoconstriction (i.e ICU patients on inotropes)

non occlusive mesenteric ischemia

obstruction

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2
Q

what is the most common form of bowel ischemia

A

colonic ischemia ..typically in elderly

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3
Q

what % of patients with colonic ischemia develop gangrene

A

15%

watershed areas are the most vulnerable

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4
Q

risk factors for bowel ischemia

A

MI

atherosclerosis

diabetes

medicine induced vasoconstriction (pressors)

aortic instrumentation/surgery

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5
Q

what is indicative of bowel ischemia on physical exam classically

A

pain may be out of proportion to exam

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6
Q

investigations for bowel ischemia

A

CBC lytes Cr lactate

plain xray

CT abdo/pelvis**

CT angio**

**–> go to for evaluating blood vessels of the gut

colonoscopy following acute event–to see the consequences of the ischemia

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7
Q

initial management of bowel ischemia

A

decision is either non operative or operative

non op–> bowel rest, fluids with or without abx, attentive observation if operation not indicated
–> ie if there was an ischemic insult suspected but appear to be improving

operative–>take to the OR if there is perforation, sepsis or suspicion of bowel ischemia with or without necrosis
–> MandM goes up with spillage of bowel contents into abdo cavity

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8
Q

management of arterial occlusion bowel ischemia

A

embolectomy/thrombectomy for revascularization

needs to be done early

may need to be done in concert with bowel resection

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9
Q

management of venous occlusion bowel ischemia

A

anticoag

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10
Q

management of hypoperfusion bowel ischemia

A

rescuscitation and attentive obs

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11
Q

management of obstructive bowel ischemia

A

conservative vs operative depending on extent and length of insult

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12
Q

what is the critical test for bowel ischemia patients?

A

CT angio

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13
Q

approach to bowel ischemia

A

hx
physical
imaging
decide is there peritonitis or is there evidence of compromised bowel? thus do they need surg

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14
Q

define diverticulosis

A

presence of diverticuli on the large bowel

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15
Q

define diverticulitis

A

inflammation of diverticuli on the large bowel

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16
Q

how do the false diverticuli in diverticulosis differ from true diverticuli (like appendix or meckels)

A

false diverticuli do not have the full thickness of the bowel wall like meckels etc. do

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17
Q

in what population are right sided diverticuli more common

A

asian

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18
Q

complications of diverticulosis

A

diverticular bleeding (5-15%)

diverticulitis (5-15%)

complicated diverticulitis (about 25% of those with diverticulitis)

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19
Q

risk factors for diverticulosis

A 
age
obesity
smoking
western diet 
low fibre diet
high fat/red meat
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20
Q

define acute diverticulitis

A

inflammation likely secondary to micro or macro perf of a diverticulum

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21
Q

define complicated diverticulitis

A

abscess

obstruction

fistula–> about 20% of patients following surgical tx of diverticulitis, most commonly involving the bladder (passing particles or air in urine is a sign)

perforation–> often present with peritonitis, sudden if big blow out (but can also present with just a bit of free air)

peritonitis

stricture–> in people who chronically have had this condition; due to cycle of inflammation and resolution

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22
Q

what is the hinchey classification

A

for diverticular disease

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23
Q

hinchey 1

A

most common

phlegmon/small pericolic abscess

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24
Q

hinchey 2

A

often require percutaneous drainage …try and avoid operating

large abscess/fistula

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25
hinchey 3
purulent peritonitis/ruptured abscess pus in the abdomen
26
hinchey 4
feculent peritontis--worst, generally need operation
27
indication for admission to hospital for diverticulitis
inability to tolerate oral intake significant comorbidities severe presentation fail to improve from outpatient management evidence of significant disease on imaging/sepsis on workup
28
how are most cases of diverticulosis/itis managed
by family doc with abx
29
non op management of diverticulitis
NPO IV fluids IV abx (i.e IV ceftriaxone and metronidazole) percutaneous drainage of abscess by IR (for larger abscesses) --> hopefully can be discharged after this colonoscopy performed after acute episode to rule out an underlying malignancy
30
if someone presents with a suspected ruptured diverticulum what test should you do and what are you ruling out
elective colonoscopy to rule out malignancy being the underlying cause
31
indications for emergency surgery to diverticulitis
unstable patient hinchey III-IV complications--> generalized peritonitis, free air, fistula, obstruction, hemorrhage, abscess
32
can you anatasmose the bowel right away in diverticulitis surgery?
no not usually if the surg was urgent... because usually lots of infection and need to make sure everything is all good before reconnecting usually wait several months to more than a year
33
in what patients can you delay surgery for diverticulitis
in those with recurrent bouts... usually not as urgent. can usually do it as an elective procedure and thus prep the bowel and in those cases can often re-anastamose the bowel during the initial surgery
34
define diarrhea
3 or more loose/watery stool per day stool weight more than 200gm/day
35
acute diarrhea ddx
``` infectious inflammatory ischemia drugs/toxins metabolic (i.e hyperthyroid) ```
36
chronic diarrhea ddx
IBD IBS chronic ischemia bowel metabolic
37
define acute diarrhea
less than 14 days
38
define chronic diarrhea
more than 30 days
39
define persistent diarreah
more than 30 days
40
what is the most common cause of chronic diarrhea
c diff (especially in hospitalized)
41
what is c diff
abx associated colitis
42
high risk abx for c diff
fluoroquinolones, clinda, cephalosporins, penicillins
43
how do you prevent c diff
soap and water is best at preventing transmission as c diff spores are resistant to alcohol based hand sanitizers
44
c diff presentation
watery diarrhea 10-15 x per day lower abdo pain/cramping can have involvement of small intestine because its an enterocolitis low grade fever leukocytosis (i.e white count that shoots up quickly) pseudomenbranous colitis on colonoscopic exam may progress to toxic megacolon
45
initial management for non severe c diff
oral metronidazole
46
mgmt for severe c diff
vanco 125mg PO QID if no progress--> vanco 500 PO QID for 10-14 days and may add IV metro as adjunct fidamocicin can be considered in patients with low tolerance to vanco
47
when do you do surgery to c diff
severe leukocytosis significantly elevated lactate peritoneal signs severe ileus toxic megacolon--> OR for total colectomy and ileostomy
48
where is UC found
isolated to large bowel, ALWAYS RECTUM
49
where is crohns found
any part of GI tract
50
is bleeding more common in crohns or UC
UC (90%)
51
is diarrhea more common crohns or UC
more common in UC--frequent small stools
52
is abdo pain more common crohns or UC
crohns--post prandial/colicky
53
is fever more common crohns or UC
crohns (uncommon in UC)
54
is tenesmus more common crohns or UC
UC
55
complications of UC
strictures, fistulae, perianal disease
56
complications of UC
toxic megacolon
57
recurrence of crohn's vs UC post op
common in crohns no risk post colectomy for UC
58
colon cancer risk in UC vs crohns
crohns--> increased if less than 30% of colon involved UC--> increased except in proctitis
59
lifestyle/diet management of IBD
smoking cessation fluids/electrolyte replacement
60
medical management of IBD
anti diarrheal agents anti inflammatory (5 ASA derivatives) antibiotics (cipro/flagyll for perianal disease in crohns) corticosteroids immunosuppressive meds--> infliximab, adalimumab (humira), methotrexate
61
what is the goal in crohns operation
preserve as much bowel as possible which still getting disease out really you are worried only about gross margins (not microscopic) --> you know there is a high likelihood of recurrence so may need another surgery so want to preserve bowel
62
indications for crohn's surgery
failure of medical management complications including fistulae, obstruction, strictures, abscess, perforation, bleeding
63
what type of surgery is the surgery for UC
ileal pouch--anal anastamosis on an elective basis
64
crohns post op complications
short bowel syndrome ileal resection less than 100cm--> watery diarrhea ileal resection more than 100cm--> steattorhea leaks strictures
65
what is short bowel syndrome
loss or small bowel surface--> increased risk of less than 50% or less than 200cm of functional small bowel
66
post surg complications for total colectomy for UC
high output ileostomy rectal stump inflammation ---usually manageable

Surgery (20 decks)

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